Online Program

An etiologic and geographical profile of mortality among the homeless in Maryland: 2004 – 2013

Monday, November 2, 2015 : 2:50 p.m. - 3:10 p.m.

Isaac Howley, MD, MPH, General Preventive Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
David Fowler, MD, Office of the Chief Medical Examiner, Maryland Department of Health and Mental Hygeine, Baltimore, MD
Carolyn Cumpsty-Fowler, PHD, MPH, Mid-Atlantic Public Health Training Center, Johns Hopkins School of Nursing and Bloomberg School of Public Health, Baltimore, MD
Context:Homeless people are vulnerable and at increased risk for mortality due to exposure and lack of shelter from environmental and social hazards. Crude mortality rates among the homeless are 3 to 4 times higher than among the general public. Vagrancy laws, mental illness, and other factors complicate epidemiologic research on the health conditions and challenges of homeless persons.

Objective: To characterize the typology and location of deaths among the homeless in Maryland.

Methods:Maryland’s Office of the Chief Medical Examiner investigations of deaths in homeless people from 2004 to 2013 were reviewed. Descriptive statistics and bivariate analyses were used to assess relationships between age, sex, race, manner, and cause of death. Incident locations were mapped to census tracts, and multiple logistic regression was used to determine the interactions between demographic factors and the distribution of homeless persons’ deaths between census tracts over a ten year period.

Results: A total of 845 individual subjects were analyzed. The mean age was 48, and 85.4% were male. Unintentional injuries killed 25.0%, and 6.0% died by homicide. Whites had greater odds than blacks of dying from acute intoxication (OR 0.60, p = 0.002), and females had greater odds than males (OR 1.53, p = 0.049). Blunt force trauma accounted for 29.4% of homicides, compared to only 2.6% of homicides in the general population. Geographical features explained only part of the variation in the odds of a homeless person’s death within a given census tract (Cox-Snell R2 = 0.137), but several factors were statistically significant in multivariate analysis. The percentage of vacant houses (p = 0.001), the percentage of population receiving SNAP benefits (p = 0.001), and the number of bus stops (p < 0.001) all increased the odds of a homeless person’s death occurring within a given census tract. Increasing median household income and the proportion of non-Hispanic African Americans (p< 0.001 for both) were associated with decreased odds of a homeless person’s death within a given tract.

Conclusions: The homeless die younger and from different causes than the general population. Acute intoxication, unintentional injury, and blunt trauma are all major causes of mortality. Deaths are more likely to occur in areas with concentrated poverty and high access to public transportation. A comprehensive death investigation system can generate many useful insights into the etiologic and geographical contributors to mortality among the homeless.

Learning Areas:


Learning Objectives:
Name two reasons why homeless people are vulnerable and at risk for death. Compare causes of mortality between the homeless and the general population. Describe the geographical features associated with locations where the homeless are more likely to die.

Keyword(s): Homelessness, Geographic Information Systems (GIS)

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a resident in General Surgery and General Preventive Medicine. I have treated numerous homeless patients following a wide variety of injuries and acute surgical illnesses. Among my scientific and clinical interests has been the epidemiology of injury and preventable morbidity among vulnerable urban populations.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.